Geographic inequalities in need and provision of social prescribing link workers.

BACKGROUND: Long-term health conditions are major challenges for care systems. Social prescribing link workers have been introduced via Primary Care Networks (PCNs) across England since 2019 to address the wider determinants of health by connecting individuals to activities, groups, or services within their local community. AIM: To assess whether the rollout of social prescribing link workers was in areas with the highest need. DESIGN AND SETTING: A retrospective study of social prescribing link workers in England from 2019 to 2023. METHOD: We combined workforce, population, survey, and area-level data at the PCN-level from April 2020 to October 2023. We measured population need prior to the rollout of link workers using reported lack of support from local services in the 2019 GP Patient Survey. To assess if rollout reflected need, we used linear regression to relate provision of link workers (measured by full-time equivalent (FTE) per 10,000 patients) in each quarter to population need for support. RESULTS: Populations in urban, more deprived areas and with higher proportions of minority ethnicities had the highest reported lack of support. Geographically these were in the North West and London. Initially, there was no association between need and provision; then from July 2022, this became negative and significant. By October 2023, a 10-percentage point higher need for support was associated with a 0.035 (95%CI(-0.634 to -0.066)) lower FTE per 10,000 patients. CONCLUSION: Rollout of link workers has not been sufficiently targeted at areas with the highest need. Future deployments should be targeted at those areas.

Gender-related self-reported mental health inequalities in primary care in England: a cross-sectional analysis using the GP Patient Survey.

BACKGROUND: Transgender, non-binary, and gender diverse people face discrimination and barriers to accessing health care. Existing evidence suggests higher rates of mental health conditions among these groups compared with binary and cisgender groups. However, information is limited by poor gender recording in health records and surveys. We aimed to provide the first national estimates of gender-related inequalities in self-reported mental health conditions and mental health support across 15 gender groups in England. METHODS: We used changes to the 2021 and 2022 nationally representative cross-sectional English General Pracitioner (GP) Patient Surveys and used age-adjusted logistic regression to predict probabilities of two outcomes: first, self-reporting a mental health condition and second, self-reporting unmet mental health needs. We report results for 15 exposure groups: five gender groups (female, male, non-binary, prefer to self-describe, and prefer not to say), within three cisgender or transgender identity groups (cisgender, transgender, or prefer not to say). We explored potential mediation by adding covariates. FINDINGS: Of the 1 520 457 respondents in the estimation sample, 861 017 (51·4%) were female, 645 300 (47·4%) were male, 2600 (0·3%) were non-binary, 2277 (0·2%) self-described their gender, and 9263 (0·7%) preferred not to state their gender. 1 499 852 (98·3%) respondents were cisgender, 7994 (0·7%) were transgender, and 12 611 (1·0%) preferred not to say their cisgender or transgender identity. We found wide gender-related inequalities in the probability of self-reporting a mental health condition, with the highest probabilities among non-binary patients who were transgender (47·21% [95% CI 42·86-51·60]) or preferred not to say their cisgender or transgender identity (32·90% [26·50-40·00]), and among transgender patients who self-described their gender (35·03% [27·39-43·53]). With the exception of non-binary patients in each case, probabilities were lowest among cisgender patient groups (ranging from male at 8·80% [8·69-8·92] to female at 11·97% [11·86-12·07]) and patients who preferred not to say their cisgender or transgender identity (ranging from female 7·15% [6·06-8·42] to prefer to self-describe 10·37% [7·13-14·86]). Inequalities in other health conditions and socioeconomic factors might mediate some of these inequalities. Probabilities of self-reported unmet mental health needs were lowest among cisgender male (15·55% [15·33-15·76]) and female (15·93% [15·76-16·10]) patients with increased probabilities among all other groups, ranging from 19·95% (17·57-22·57) in transgender male patients to 28·64% (26·23-31·17) among patients who preferred not to say their gender or their cisgender or transgender identity. Inequalities in interactions with health-care professionals may mediate much of these inequalities. INTERPRETATION: Together with existing evidence, our findings showed large gender-related inequalities in self-reported mental health outcomes in England. Given the existence of self-reported unmet mental health needs, we suggest that better health care system inclusivity and health-care professional training are needed, alongside broader improvements in the social and legal environment for transgender, non-binary, and gender diverse people. FUNDING: National Institute for Health and Care Research.

Risk factors for deaths of despair in England: An ecological study of local authority mortality data.

Deaths of Despair (DoD) are socially patterned fatalities encompassing those attributable to drug and alcohol misuse and suicide. DoD occur much more frequently in socially deprived communities. This ecological study aimed to yield new knowledge on the spatial distribution of DoD, and socioeconomic factors that predict DoD risk in England. Via ICD-10 coding, deaths nationally during 2019-2021 were classified to non-overlapping categories of drug-related death, alcohol-specific death, and suicide. The proportion of DoD from each of these causes was calculated and age standardised DoD rates were generated for local authorities. A multivariable regression model for DoD risk was developed using 25 socioeconomic indicators. In 2019-2021, an estimated 46,200 people lost their lives due to DoD. Rates were higher in the North and in coastal areas (p < 0.001), ranging regionally from 25.1/100,000 (SD 6.3) in London to 54.7/100,000 (SD 9.5) in the North East. Alcohol-specific deaths were the largest contributor of DoD, accounting for 44.1% (95%CI 43.5-44.8%) of all such deaths. Living in the North, unemployment, White British ethnicity, living alone, economic inactivity, employment in elementary occupations, and living in urban areas were significantly associated with elevated DoD risk. DoD in England are spatially patterned, with northern regions experiencing a much higher burden of mortality from these avoidable causes. This study provides novel insights into the area-level factors associated with DoD in England. Potential ecological error is a key limitation.

Impact of Parental Mental Health and Poverty on the Health of the Next Generation: A Multi-Trajectory Analysis Using the UK Millennium Cohort Study.

PURPOSE: Exposure to parental mental ill-health and poverty in childhood impact health across the lifecourse. Both maternal and paternal mental health may be important influences, but few studies have unpicked the complex interrelationships between these exposures and family poverty for later health. METHODS: We used longitudinal data on 10,500 children from the nationally representative UK millennium cohort study. Trajectories of poverty, maternal mental health, and secondary caregiver mental health were constructed from child age of 9 months through to 14 years. We assessed the associations of these trajectories with mental health outcomes at the age of 17 years. Population-attributable fractions were calculated to quantify the contribution of caregivers' mental health problems and poverty to adverse outcomes at the country level. RESULTS: We identified five distinct trajectories. Compared with children with low poverty and good parental mental health, those who experienced poverty and poor primary or secondary caregiver mental health (53%) had worse outcomes. Children exposed to both persistent poverty and poor caregiver mental health were at markedly increased risk of socioemotional behavioural problems (aOR 4.2; 95% CI 2.7-6.7), mental health problems (aOR 2.5; CI 1.6-3.9), and cognitive disability (aOR 1.7; CI 1.1-2.5). We estimate that 40% of socioemotional behavioural problems at the age of 17 were attributable to persistent parental caregivers' mental health problems and poverty. DISCUSSION: More than half of children growing up in the UK are persistently exposed to either one or both of poor caregiver mental health and family poverty. The combination of these exposures is strongly associated with adverse health outcomes in the next generation.

Risk of Falls and Fractures in Individuals With Cataract, Age-Related Macular Degeneration, or Glaucoma.

Importance: Three leading disease causes of age-related visual loss are cataract, age-related macular degeneration (AMD), and glaucoma. Although all 3 eye diseases have been implicated with falls and fracture risk, evidence is mixed, with the contribution of different eye diseases being uncertain. Objective: To examine whether people with cataract, AMD, or glaucoma have higher risks of falls or fractures than those without. Design, Setting, and Participants: This cohort study was a population-based study in England using routinely collected electronic health records from the Clinical Practice Research Datalink (CPRD) GOLD and Aurum primary care databases with linked hospitalization and mortality records from 2007 to 2020. Participants were people with cataract, AMD, or glaucoma matched to comparators (1:5) by age, sex, and general practice. Data were analyzed from May 2021 to June 2023. Exposures: For each eye disease, we estimated the risk of falls or fractures using separate multivariable Cox proportional hazards regression models. Main Outcomes: Two primary outcomes were incident falls and incident fractures derived from general practice, hospital, and mortality records. Secondary outcomes were incident fractures of specific body sites. Results: A total of 410 476 people with cataract, 75 622 with AMD, and 90 177 with glaucoma were matched (1:5) to 2 034 194 (no cataract), 375 548 (no AMD), and 448 179 (no glaucoma) comparators. The mean (SD) age was 73.8 (11.0) years, 79.4 (9.4) years, and 69.8 (13.1) years for participants with cataract, AMD, or glaucoma, respectively. Compared with comparators, there was an increased risk of falls in those with cataract (adjusted hazard ratio [HR], 1.36; 95% CI, 1.35-1.38), AMD (HR, 1.25; 95% CI, 1.23-1.27), and glaucoma (HR, 1.38; 95% CI, 1.35-1.41). Likewise for fractures, there were increased risks in all eye diseases, with an HR of 1.28 (95% CI, 1.27-1.30) in the cataract cohort, an HR of 1.18 (95% CI, 1.15-1.21) for AMD, and an HR of 1.31 (95% CI, 1.27-1.35) for glaucoma. Site-specific fracture analyses revealed increases in almost all body sites (including hip, spine, forearm, skull or facial bones, pelvis, ribs or sternum, and lower leg fractures) compared with matched comparators. Conclusions and Relevance: The results of this study support recognition that people with 1 or more of these eye diseases are at increased risk of both falls and fractures. They may benefit from improved advice, access, and referrals to falls prevention services.

Age-gender differences in the relationships between physical and mental health.

Previous studies have identified that smoking, exercise and breadth of social interaction mediate the strong associations between physical and mental health. However, these studies have been restricted to older populations, have not explored differences by gender, and have not considered online social interaction. We explore how the effects of four mediators (exercise, smoking, in-person and online social interaction) of the two-way relationships between past and future physical and mental health vary across eight age and gender groups. We use data from a representative sample of the UK population consisting of 175,779 observations on 41,995 adults from Understanding Society (UKHLS) between 2009 and 2019. Within a mediation framework, we estimate the percentage of the total effects that can be explained by the proposed mediating factors. We show that exercise, smoking, in-person and online social interaction are significant mediators of the effect of mental health on future physical health. In-person social interaction is the largest of these, accounting for 2.3% of the total effect. Smoking, in-person and online interaction are significant mediators of the effect of physical health on future mental health. Again, in-person interaction is the largest of these, accounting for 3.0% of the total effect. The percentages of the total effects mediated by each factor differ substantially by age and gender. Seeking to avoid the harmful effects of poor physical health on future mental health should focus on increasing physical activity in older men, and on increasing in-person social interaction in both men and women. Seeking to avoid the harmful effects of poor mental health on future physical health should focus on increasing physical activity and in-person social interaction in older men and women, and on reducing smoking in younger men and women.

Deaths of despair in England: an observational study of local authority mortality data.

BACKGROUND: Deaths of Despair (DoD) are socially patterned causes of death encompassing drug and alcohol misuse and suicide. DoDs are strongly associated with socioeconomic disadvantage. England has high levels of inequalities, so we hypothesised the existence of marked geographical variations in DoD. We aimed to yield new knowledge on the spatial distribution of DoD, and area-level socioeconomic factors that predict DoD risk in England. METHODS: This observational study was conducted using ICD-10 coded deaths for 307 local authorities in England during 2019-21. Deaths were grouped to non-overlapping categories of drug-related death, alcohol-specific death, and suicide. The mean contributions of each of these causes to the total number of DoD in England were calculated with Poisson exact confidence intervals. Standardised mortality ratios (SMRs) for DoD were generated for each local authority population. A multivariable regression model for DoD risk was developed using 25 socioeconomic variables. FINDINGS: An estimated 46 200 people lost their lives due to DoD between Jan 1, 2019, and Dec 31, 2021. Regional SMRs ranged from 57·4 (SD 16·1) in London to 144·1 (SD 26·8) in the northeast of England (p<0·0001). Alcohol-specific deaths were the largest contributor of DoD, accounting for 44·1% of DoD (95% CI 43·5-44·8), followed by drug-related death (28·1%, 27·7-28·6) and suicide (27·7%, 27·2-28·2). Living in the North, living alone, White British ethnicity, lower inward migration, economic inactivity, income deprivation in older people, employment in elementary occupations, unemployment, and education deprivation in adults were significantly associated with higher DoD rates in England. INTERPRETATION: DoD in England are spatially patterned, with northern regions experiencing a considerably higher burden of mortality from these avoidable causes. A key limitation is ecological bias. This study provides novel insights into area-level risk factors for DoD in England. FUNDING: National Institute for Health and Care Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM).

Evaluating socioeconomic inequalities in influenza vaccine uptake during the COVID-19 pandemic: A cohort study in Greater Manchester, England.

BACKGROUND: There are known socioeconomic inequalities in annual seasonal influenza (flu) vaccine uptake. The Coronavirus Disease 2019 (COVID-19) pandemic was associated with multiple factors that may have affected flu vaccine uptake, including widespread disruption to healthcare services, changes to flu vaccination eligibility and delivery, and increased public awareness and debate about vaccination due to high-profile COVID-19 vaccination campaigns. However, to the best of our knowledge, no existing studies have investigated the consequences for inequalities in flu vaccine uptake, so we aimed to investigate whether socioeconomic inequalities in flu vaccine uptake have widened since the onset of the COVID-19 pandemic. METHODS AND FINDINGS: We used deidentified data from electronic health records for a large city region (Greater Manchester, population 2.8 million), focusing on 3 age groups eligible for National Health Service (NHS) flu vaccination: preschool children (age 2 to 3 years), primary school children (age 4 to 9 years), and older adults (age 65 years plus). The sample population varied between 418,790 (2015/16) and 758,483 (2021/22) across each vaccination season. We estimated age-adjusted neighbourhood-level income deprivation-related inequalities in flu vaccine uptake using Cox proportional hazards models and the slope index of inequality (SII), comparing 7 flu vaccination seasons (2015/16 to 2021/22). Among older adults, the SII (i.e., the gap in uptake between the least and most income-deprived areas) doubled over the 7 seasons from 8.48 (95% CI [7.91,9.04]) percentage points to 16.91 (95% CI [16.46,17.36]) percentage points, with approximately 80% of this increase occurring during the pandemic. Before the pandemic, income-related uptake gaps were wider among children, ranging from 15.59 (95% CI [14.52,16.67]) percentage points to 20.07 (95% CI [18.94,21.20]) percentage points across age groups and vaccination seasons. Among preschool children, the uptake gap increased in 2020/21 to 25.25 (95% CI [24.04,26.45]) percentage points, before decreasing to 20.86 (95% CI [19.65,22.05]) percentage points in 2021/22. Among primary school children, inequalities increased in both pandemic years to reach 30.27 (95% CI [29.58,30.95]) percentage points in 2021/22. Although vaccine uptake increased during the pandemic, disproportionately larger increases in uptake in less deprived areas created wider inequalities in all age groups. The main limitation of our approach is the use of a local dataset, which may limit generalisability to other geographical settings. CONCLUSIONS: The COVID-19 pandemic led to increased inequalities in flu vaccine uptake, likely due to changes in demand for vaccination, new delivery models, and disruptions to healthcare and schooling. It will be important to investigate the causes of these increased inequalities and to examine whether these increased inequalities also occurred in the uptake of other routine vaccinations. These new wider inequalities in flu vaccine uptake may exacerbate inequalities in flu-related morbidity and mortality.

Analysing changes to the flow of public funding within local health and care systems: An adaptation of the System of Health Accounts framework to a local health system in England.

Financial flows relating to health care are routinely analysed at national and international level. They have rarely been systematically analysed at local level, despite sub-national variation due to population needs and decisions enacted by local organisations. We illustrate an adaptation of the System of Health Accounts framework to map the flow of public health and care funding within local systems, with an application for Greater Manchester (GM), an area in England which agreed a health and social care devolution deal with the central government in 2016. We analyse how financial flows changed in GM during the four years post-devolution, and whether spending was aligned with local ambitions to move towards prevention of ill-health and integration of health and social care. We find that GM decreased spending on public health by 15%, and increased spending on general practice by 0.1% in real terms. The share of total local expenditure paid to NHS Trusts for general and acute services increased from 70.3% to 71.6%, while that for community services decreased from 11.7% to 10.3%. Results suggest that GM may have experienced challenges in redirecting resources towards their goals. Mapping financial flows at a local level is a useful exercise to examine whether spending is aligned with system goals and highlight areas for further investigation.

The impact of devolution on experienced health and well-being.

Devolution of health systems from national to local levels is a common focus of policymakers across the world. The overarching aim is to improve population health by better meeting the specific needs of local citizens. We examine the case of a coordinated devolution across several public service sectors in Greater Manchester, England, in 2016. We estimate the impact on experienced health and well-being using Short-Form 12 scores from 13,938 adult respondents to the UK Household Longitudinal Survey between 2012 and 2020. We use difference-in-differences and lagged-dependent variable regressions to compare Greater Manchester to the rest of England. We find no statistically significant changes in experienced health and well-being over the four years following the start of devolution. Our findings suggest that devolving population health management alone without budgetary powers and local accountability mechanisms may not be effective in improving experienced health and well-being in the relatively short-term.

The social capital penalty paid by teetotallers.

Social capital is important and helps protect health and reduce loneliness. Governments worldwide are pursuing policies to reduce the amount of alcohol consumed to protect public health but alcohol consumption remains a prevalent feature of social interaction in the UK. Previous studies have identified a strong relationship between alcohol and social capital which varies in direction depending on the dimension of social capital studied. Using a large nationally representative longitudinal dataset for the UK, we apply an outcome-wide longitudinal design for causal inference, adjusting for covariates, as well as lagged values of outcome and exposure, to investigate if drinking less alcohol or not drinking alcohol at all is related to five binary social capital outcomes: socialising, being active in an organization, feeling lonely, number of close friends, and a bridging social capital score. We use two drinking exposures, binary drinker status, and categorised drinking frequency. We find that not drinking alcohol is negatively associated with socialising. Analysis using the frequency of drinking alcohol exposure finds drinking alcohol monthly or less is negatively associated with being active in an organisation. We find little evidence of any relationship between drinking alcohol and feelings of loneliness, number of friends and bridging social capital. Our results suggest that non-drinkers face barriers to some forms of social capital including socialising, which could be due to alcohol being a social norm in the UK. However, our results also suggest that high-frequency drinkers can reduce their drinking with minimal impact on their social capital. Our findings suggest more needs to be done to make socialising easier for non-drinkers. Furthermore, our findings support the implementation of policies to reduce high-frequency drinking.

Estimating the heterogeneous health and well-being returns to social participation.

Social participation is defined as an individual's involvement in activities that provide connections with others in society. Past research has demonstrated links between social participation, improved health and well-being, and reduced social isolation, but has been restricted to older people and has not investigated heterogeneity. Using cross-sectional data from the UK's Community Life Survey (2013-2019; N = 50,006), we estimated returns to social participation in the adult population. We included availability of community assets as instruments in a marginal treatment effects model, which allows treatment effects to be heterogeneous and examines whether the effects vary by propensity to participate. Social participation was linked to reduced loneliness and improved health (-0.96 and 0.40 points respectively on 1-5 scales) and increased life satisfaction and happiness (2.17 and 2.03 points respectively on 0-10 scales). These effects were larger for those on low income, with lower education attainment, and who live alone or with no children. We also found negative selection, indicating those less likely to participate have higher health and well-being returns. Future interventions could focus on increasing community asset infrastructure and encouraging social participation for those with lower socio-economic status.

Exploring the health and sociodemographic characteristics of people seeking advice with claiming universal credit: a cross-sectional analysis of UK citizens advice data, 2017-2021.

BACKGROUND: The UK Department for Work and Pensions (DWP) administers Universal Credit (UC) - the main UK benefit for people in- and out-of-work. UC is being rolled out nationally from 2013 to 2024. Citizens Advice (CA) is an independent charity that provides advice and support to people making a claim for UC. The aim of this study is to understand who is seeking advice from CA when making a UC claim and how the types of people seeking advice are changing as the rollout of UC continues. METHODS: Co-developed with Citizens Advice Newcastle and Citizens Advice Northumberland we performed longitudinal analysis of national data from Citizens Advice for England and Wales on the health (mental health and limiting long term conditions) and socio-demographic of 1,003,411 observations for people seeking advice with claiming UC over four financial years (2017/18 to 2020/21). We summarised population characteristics and estimated the differences between the four financial years using population-weighted t-tests. Findings were discussed with three people with lived experience of seeking advice to claim UC to help frame our interpretation and policy recommendations. RESULTS: When comparing 2017/18 to 2018/19, there was a significantly higher proportion of people with limiting long term conditions seeking advice with claiming UC than those without (+ 2.40%, 95%CI: 1.31-3.50%). However, as the rollout continued between 2018/29 and 2019/20 (-6.75%, 95%CI: -9.62%--3.88%) and between 2019/20 and 2020/21 (-2.09%, 95%CI: -2.54%--1.64%), there were significantly higher proportions of those without a limiting long term condition seeking advice than with. When comparing 2018/19 to 2019/20 and 2019/20 to 2020/21, there was a significant increase in the proportion of self-employed compared to unemployed people seeking advice with claiming UC (5.64%, 95%CI: 3.79-7.49%) and (2.26%, 95%CI: 1.29-3.23%) respectively. CONCLUSION: As the rollout for UC continues, it is important to understand how changes in eligibility for UC may impact on those who need help with applying for UC. Ensuring that the advice process and application process is responsive to a range of people with different needs can help to reduce the likelihood that the process of claiming UC will exacerbate health inequalities.

Longitudinal Associations between Peer and Family Relationships, Emotional Symptoms, and Regional Brain Volume across Adolescence.

The period of adolescence brings with it a dynamic interaction between social context and behaviour, structural brain development, and anxiety and depressive symptoms. The rate of volumetric change in the ventromedial prefrontal cortex (vmPFC) and amygdala have been implicated in socioemotional development in adolescence; typically, there is thinning of grey matter volume (GMV) in the vmPFC and growth in the amygdala during this time. The directionality of the associations between social, emotional, and neuroanatomical factors has yet to be untangled, such as the degree to which social variables impact regional brain development, and vice versa. To add, the differences between sexes are still up for debate. In this study, longitudinal associations between peer problems, family support, socioeconomic stress, emotional symptoms, amygdala volume, and vmPFC GMV were investigated for both sexes using latent change score models. Data from a multi-site European study at baseline (mean (SD) age = 14.40 (0.38) years; % female = 53.19) and follow-up 2 (mean (SD) age = 18.90 (0.69) years, % female = 53.19) were used. Results revealed that peer problems did not predict emotional symptoms, rather they changed together over time. For males only, there was positive correlated change between vmPFC GMV, peer problems and emotional symptoms, indicating that slower vmPFC GMV thinning was associated with poorer social and emotional functioning. Additionally, greater family support at age 14 years was associated with slower growth of amygdala volume between ages 14 and 19 years for males; previous research has related slower amygdala growth to resilience to mental health disorders. The findings have extended understanding of mutual social, emotional and brain development, and avenues to protect mental health.

Social environment and brain structure in adolescent mental health: A cross-sectional structural equation modelling study using IMAGEN data.

Adolescent mental health is impacted by a myriad of factors, including the developing brain, socioeconomic conditions and changing social relationships. Studies to date have neglected investigating those factors simultaneously, despite evidence of their interacting effects and distinct profiles for males and females. The current study addressed that gap by applying structural equation modelling to IMAGEN data from adolescents aged 14 years (n = 1950). A multi-group model split by sex was tested with the variables of socioeconomic stress, family support, peer problems, and brain structure as predictors, and emotional symptoms as the main outcome. Findings indicated that, for both sexes, peer problems were positively associated with emotional symptoms, and socioeconomic stress was negatively associated with family support. Additionally, there were sex-specific findings within the full models: ventromedial prefrontal cortex grey matter volume was negatively associated with emotional symptoms for males when corrected for whole brain volume, and socioeconomic stress was negatively associated with whole brain volume for females. This study underscores the importance of the peer environment for early adolescent emotional symptoms in both boys and girls, but goes further to suggest distinct gender associations with socioeconomic factors and brain structure which provides a multi-level view of risk and resilience. Future research could exploit existing IMAGEN longitudinal data to strengthen causal claims and to determine the potential longstanding impact of social environment and brain development on adolescent mental health.

Associations between inflexible job conditions, health and healthcare utilisation in England: retrospective cross-sectional study.

OBJECTIVES: To estimate the strength of association between having an inflexible job and health-related quality of life and healthcare utilisation; and to explore heterogeneity in the effects by gender, age and area-level deprivation. DESIGN: Retrospective cross-sectional study. SETTING: Seven waves of the English General Practice Patient Survey between 2012 and 2017. PARTICIPANTS: 1 232 884 people aged 16-64 years and in full-time employment. We measured job inflexibility by inability to take time away from work during usual working hours to seek medical care. PRIMARY AND SECONDARY OUTCOME MEASURES: Health-related quality of life (EQ-5D-5L); number of months since the respondent last saw a general practitioner (GP) or nurse; use of out-of-hours general practice in the past 6 months. We used regression analyses to estimate the strength of association between outcomes and having an inflexible job, adjusting for person and area-level characteristics. RESULTS: One-third of respondents reported job inflexibility. The probability of job inflexibility was higher at younger ages and in more deprived areas. Job inflexibility was associated with lower EQ-5D-5L utility scores of 0.017 (95% CI 0.016 to 0.018) for women and 0.016 (95% CI 0.015 to 0.017) for men. Women were more affected than men in the mental health domain. The reduction in health-related quality of life associated with having an inflexible job was greater for employees who were older or lived in more deprived areas. Having an inflexible job was associated with a longer time since the last visit to their GP of 0.234 (95% CI 0.201 to 0.268) months for women and 0.199 (95% CI 0.152 to 0.183) months for men. CONCLUSIONS: Inequalities in the prevalence of inflexible jobs contribute to inequalities in health. One mechanism may be through reduced access to healthcare. Policymakers and employers should ensure that all employees have sufficient job flexibility to protect their health.

COVID-19 and deprivation amplification: An ecological study of geographical inequalities in mortality in England.

'Deprivation amplification' is used to understand the relationship between deprivation, scale and COVID-19 mortality rates. We found that more deprived Middle Super Output Areas (MSOAs) in the more deprived northern regions suffered greater COVID-19 mortality rates. Across England, the most deprived 20% of MSOAs had higher mortality than the least deprived (44.1% more COVID-19 deaths/10,000). However, the most deprived MSOAs in the north fared worse than equally deprived areas in the rest of England (14.5% more deaths/10,000, beta = 0.136, p < 0.01). There was also strong evidence of spatial clustering and spill-overs. We discuss these findings in relation to 'deprivation amplification', the 'syndemic pandemic', and the health and place literature.

The impact of COVID-19 lockdowns on physical activity amongst older adults: evidence from longitudinal data in the UK.

BACKGROUND: A sedentary lifestyle increases the risk of adverse health outcomes and frailty,particularly for older adults. To reduce transmission during the COVID-19 pandemic, people were instructed to stay at home, group sports were suspended, and gyms were closed, thereby limiting opportunities for physical activity. Whilst evidence suggests that physical activity levels reduced during the pandemic, it is unclear whether the proportion of older adults realising the recommended minimum level of physical activity changed throughout the various stages of lockdown. METHODS: We used a large sample of 3,660 older adults (aged ≥ 65) who took part in the UK Household Longitudinal Study's annual and COVID-19 studies. We examined changes in the proportion of older adults who were realising the UK Chief Medical Officers' physical activity recommendations for health maintenance at several time points before and after COVID-19 lockdowns were imposed. We stratified these trends by the presence of health conditions, age, neighbourhood deprivation, and pre-pandemic activity levels. RESULTS: There was a marked decline in older adults' physical activity levels during the third national lockdown in January 2021. The proportion realising the Chief Medical Officers' physical activity recommendations decreased from 43% in September 2020 to 33% in January 2021. This decrease in physical activity occurred regardless of health condition, age, neighbourhood deprivation, or pre-pandemic activity levels. Those doing the least activity pre-lockdown increased their activity during lockdowns and those doing the most decreased their activity levels. CONCLUSIONS: Reductions in older adults' physical activity levels during COVID-19 lockdowns have put them at risk of becoming deconditioned and developing adverse health outcomes. Resources should be allocated to promote the uptake of physical activity in older adults to reverse the effects of deconditioning.

Family doctor responses to changes in target stringency under financial incentives.

Healthcare providers may game when faced with targets. We examine how family doctors responded to a temporary but substantial increase in the stringency of targets determining payments for controlling blood pressure amongst younger hypertensive patients. We apply difference-in-differences and bunching techniques to data from electronic health records of 107,148 individuals. Doctors did not alter the volume or composition of lists of their hypertension patients. They did increase treatment intensity, including a 1.2 percentage point increase in prescribing antihypertensive medicines. They also undertook more blood pressure measurements. Multiple testing increased by 1.9 percentage points overall and by 8.8 percentage points when first readings failed more stringent target. Exemption of patients from reported performance increased by 0.8 percentage points. Moreover, the proportion of patients recorded as exactly achieving the more stringent target increased by 3.1 percentage points to 16.6%. Family doctors responded as intended and gamed when set more stringent pay-for-performance targets.

Evaluation of the mental health impacts of Universal Credit: protocol for a mixed methods study.

INTRODUCTION: The UK social security system is being transformed by the implementation of Universal Credit (UC), which combines six existing benefits and tax credits into a single payment for low-income households. Despite extensive reports of hardship associated with the introduction of UC, no previous studies have comprehensively evaluated its impact on mental health. Because payments are targeted at low-income households, impacts on mental health will have important consequences for health inequalities. METHODS AND ANALYSIS: We will conduct a mixed methods study. Work package (WP) 1 will compare health outcomes for new recipients of UC with outcomes for legacy benefit recipients in two large population surveys, using the phased rollout of UC as a natural experiment. We will also analyse the relationship between the proportion of UC claimants in small areas and a composite measure of mental health. WP2 will use data collected by Citizen's Advice to explore the sociodemographic and health characteristics of people who seek advice when claiming UC and identify features of the claim process that prompt advice-seeking. WP3 will conduct longitudinal in-depth interviews with up to 80 UC claimants in England and Scotland to explore reasons for claiming and experiences of the claim process. Up to 30 staff supporting claimants will also be interviewed. WP4 will use a dynamic microsimulation model to simulate the long-term health impacts of different implementation scenarios. WP5 will undertake cost-consequence analysis of the potential costs and outcomes of introducing UC and cost-benefit analyses of mitigating actions. ETHICS AND DISSEMINATION: We obtained ethical approval for the primary data gathering from the University of Glasgow, College of Social Sciences Research Ethics Committee, application number 400200244. We will use our networks to actively disseminate findings to UC claimants, the public, practitioners and policy-makers, using a range of methods and formats. TRIAL REGISTRATION NUMBER: The study is registered with the Research Registry: researchregistry6697.